Who Defines Futility?

FOR THE past two decades, our society has struggled to identify the proper circumstances under which life-sustaining medical treatment should be limited. In fact, we seem to have reached a consensus on some aspects of the problem. It is generally agreed that a competent patient has the right to refuse life-sustaining treatment; when the patient is not competent, family members may limit treatment to serve the patient's best interests. The report by Murphy1in this issue ofTHE JOURNALexamines a more controversial question that is currently at the forefront of the treatment-limitation debate—ie, under what circumstances can life-sustaining interventions be limitedwithoutthe informed consent of the patient or family? Murphy notes correctly that cardiopulmonary resuscitation (CPR) is "rarely effective and in many cases futile" in the setting of a long-term—care facility, where many elderly patients are chronically ill or severely demented. He proposes a policy that "enables